Provider Demographics
NPI:1285242271
Name:SOULSTICE SPA LLC
Entity type:Organization
Organization Name:SOULSTICE SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:KAYSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GEHRET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-847-1644
Mailing Address - Street 1:512A JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-2123
Mailing Address - Country:US
Mailing Address - Phone:415-847-1644
Mailing Address - Fax:
Practice Address - Street 1:2462 W 3RD ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-6425
Practice Address - Country:US
Practice Address - Phone:707-843-3539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty